LTOB Stars Enrollment Form

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Email Address *

Name/Age of child participating (and preferred nickname if applicable) *

Name(s) of Parent(s) or Guardian(s) *

Address *

Phone Number *

Emergency Contact Name and Phone Number *

Please list any accommodations your child may require to participate in our program

MINOR PHOTO RELEASE: Little Theatre on the Bay has my permission to use my child's photograph publicly to promote the theatre. I understand the images may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee, or other compensation shall become payable to me by reason of such use. *

Yes

MEDICAL INFORMATION: Please List Primary Care Physician's Name and Phone Number *

MEDICAL INFORMATION: Please List Medical Insurance Provider and Policy Number *

MEDICAL INFORMATION: Allergies to medications? Medical Conditions for which the minor is receiving treatment? Prescription Drugs the minor is taking? Other pertinent medical information? Please List Below. *

EMERGENCY MEDICAL CONSENT: As custodian of the aforementioned minor, I grant my authorization and consent for a designated adult to administer general first aid treatment for minor injuries or illnesses. If the injury or illness is severe, I authorize him or her to seek professional emergency personnel to attend, transport, and treat the minor and to issue consent for medical care deemed advisable by a licensed medical professional or institution. I authorize the designated adult to exercise best judgement upon the advice of medical or emergency personnel. *

Yes

TRANSPORATION: Please specify if you have any transportation needs that would otherwise be a barrier for your child to attend this workshop. We will do our best to accommodate these needs but cannot guarantee fulfillment of all requests.

We have a vehicle but would need help via gas card or mileage reimbursement.

We do have have a vehicle and would need a ride via bus or ride share to and from the theatre.

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